CurrentAnthemPolicy 06-001

Implant Fixed Prosthetics - Crowns and Fixed Bridges

Governance for dental implant-supported crowns, abutment-supported crowns, and implant-supported fixed partial dentures — clinical indications, documentation, and coding considerations for Anthem dental plans and affected members/providers.

Policy Summary

PayerAnthem

PolicyImplant Fixed Prosthetics - Crowns and Fixed Bridges

Policy CodePolicy 06-001

Change TypeNo material changes

Effective DateJan 1, 2022

Next Review Date

Key ActionObtain and submit a complete exam, imaging (radiographs within 12 months) and treatment plan prior to implant placement and restoration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~40+CDT procedure codes listed

12radiograph recency (months)

1letter of dental necessity required

25+references listed

5revision entries

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Medically necessary implant prosthetic criteria

Covered when ALL of the following are met

Primary indications: Implant-supported crowns, abutment-supported crowns, or implant-supported fixed partial dentures are appropriate when replacement is due to accidental traumatic injury with extraction, pathologic disorder resulting in extraction, congenitally missing teeth, or congenital disorders of teeth resulting in extraction.

Pre-procedure requirements: Prior to implant placement/restoration a thorough dental examination, medical and dental history, full mouth imaging, and treatment plan must be completed.

See documentation and prior authorization requirements for required imaging and records.

Imaging and documentation: Diagnostic radiographic images within the past 12 months are required; when necessity is not obvious on radiographs, intra-oral photographs and narrative treatment notes must accompany images.radiographs within 12 months

Appliance retention exception: A patient’s inability to wear a removable appliance due to limited retention may qualify for implant placement when documented by a letter of dental necessity from the treating provider, with supporting radiographic evidence and a history of failed corrective procedures.

Letter of dental necessity and radiographic evidence required.

Plan/contract conditions: Coverage is subject to group contract terms including missing tooth clauses, alternate benefit provisions, and specific plan exclusions (for example, implant placement/restoration is not a covered benefit for third molar sites).

Alternate benefit or contract provisions may apply; plans with a missing tooth clause provide no benefit for planned implant replacement.

Repairs/replacements: Repair or replacement of implant prosthetics (e.g., fractured porcelain, loose or broken screws) requires a detailed narrative and is contract dependent.

Benefits for repair/replacement depend on group contract.

Not medically necessary / exclusions

Not covered / not medically necessary when ANY of the following apply

No missing tooth: When teeth are not missing — including replacement of third molars — implant-supported restorations are not appropriate and not covered.

Multiple-teeth replacement when alternatives exist: Replacement of multiple teeth in the same arch is not medically necessary when less costly dental services can adequately restore occlusion to function (unless group contract specifies otherwise).

Alternate benefit provisions may be applied if specified by contract.

Tooth-implant supported FPDs: Tooth-implant supported fixed partial dentures may not be considered for benefits due to lower reported survival rates compared with solely implant- or tooth-supported FPDs; coverage for these is plan specific.

This provision is plan specific based on available evidence and contract terms.

Implant placement and restoration for dental implant‑supported crowns, abutment‑supported crowns, and implant‑supported fixed partial dentures is subject to contract terms and clinical criteria. Implant procedures are not appropriate when teeth are not missing (including replacement of third molars) and are not a covered benefit for third molar sites. Replacement of multiple teeth in the same arch is not medically necessary when less costly dental services can adequately restore occlusion to function, unless the group contract specifies otherwise. Prosthetic restoration of implants may be limited by alternate benefit provisions or other plan contract language; if a subscriber does not return for cementation, the service is considered incomplete and no benefit is available.

Adoption of the Clinical Utilization Management (UM) Guideline is optional at the plan or line‑of‑business level. Federal, state, and contract language and other dental policy take precedence; individual plans may elect to use this guideline when performing utilization review. To determine whether this Clinical UM Guideline is applied for a given member, contact the customer service number on the member’s ID card.

When less costly, clinically adequate dental services can restore occlusion and function, those alternatives should be considered before approving implant‑supported restorations. Plans with alternate benefit provisions may apply an alternate benefit in lieu of implant prosthetics; coverage determinations for multiple‑tooth replacement rely on whether less costly options can achieve satisfactory function per the group contract.

Coding and Radiographs

CDT Codes (informational)mixed

D6010	Surgical placement of implant body; endosteal implant
D6011	Surgical access to an implant body (second stage implant surgery)
D6013	Surgical placement of mini implant
D6055	Connecting bar implant or abutment supported
D6057	Custom fabricated abutment includes placement
D6051	Interim implant abutment placement
D6052	Semi-precision attachment abutment
D6110	Implant/abutment supported removable denture for edentulous arch maxillary
D6111	Implant/abutment supported removable denture for edentulous arch mandibular
D6112	Implant/abutment supported removable denture for partially edentulous arch maxillary

1–10 of 66

1/7

Diagnosis Codes NoteICD-10

See current CDT code book

ICD-10-CM Diagnoses for Dental Diseases and Conditions: See the current CDT code book for details

Coding Referencemixed

CDT 2022

Current Dental Terminology CDT 2022 American Dental Association

Literature Citationsmixed

No codes listed

Radiograph Recency

Required RadiographsDiagnostic radiographic images within the preceding 12 months are required to document necessity for implant-supported restorations

Provider Actions, Authorization & Documentation

Note

Plan Implementation / Utilization Review

Plans may choose whether to implement this Clinical UM Guideline for utilization review. To determine if review or prior authorization is required for this guideline, contact the customer service number on the member's ID card. Plans or lines of business may also use the guideline for provider education or to review services for specified providers whose billing or claims patterns trigger review.

Plans may elect to implement guideline for utilization review
Contact customer service to confirm plan-specific requirements

Documentation Required

Prior Authorization / Documentation Requirements

Prior to implant placement and restoration, a complete dental exam, full medical/dental history, diagnostic imaging (radiographs taken within the preceding 12 months), and a detailed treatment plan including intra-oral photographs and narrative (when radiographs alone are insufficient) must be submitted when requesting review or prior authorization. Temporary/provisional restorations are considered inclusive with the final restoration. Documentation supporting metal allergy/sensitivity must include physician documentation and allergy report.

Complete exam, history, imaging and treatment plan required before implant placement/restoration
Diagnostic radiographic images within preceding 12 months; intra-oral photos and narrative if radiographs are not definitive
Physician documentation required for metal allergy/sensitivity cases
Temporary/provisional restorations considered inclusive with final restoration

Billing Rule

Alternate / Less Costly Services

Consider less costly, contract-allowed alternatives before providing implant-supported restorations. When alternate benefit provisions exist, an alternate benefit may be applied to replace missing teeth per group contract. Implant placement/restoration is not a covered benefit for third molar (wisdom tooth) sites.

Apply alternate (less costly) services when group contract allows
No coverage for implants at third molar sites
Replacement of multiple teeth by implants may be not medically necessary if less costly services can restore function

Denial Risk

Situations That May Trigger Denial

Replacement when teeth are not missing, or when restorable alternatives exist, may be denied. Plans that contain a missing tooth clause may deny benefits for implant replacement when the clause applies. Incomplete services (e.g., subscriber does not return for cementation) will not be considered a benefit.

Denial risk if teeth are not missing or restorable alternatives exist
Missing tooth clauses may preclude benefit for implant replacement
No benefit for incomplete services (e.g., no cementation)

Billing Rule

Coding Standard Reference

Use Current Dental Terminology (CDT) 2022 for procedure coding and documentation.

CDT 2022 (American Dental Association) must be used for coding

Prior Authorization

Provider Action / Required Documentation

Provider action: When requesting review or prior authorization, include all required diagnostic records (exam, history, imaging, treatment plan, intra-oral photographs, and narratives as applicable). Verify plan-specific implementation and prior authorization requirements with the payor.

Include exam, medical/dental history, diagnostic radiographs, treatment plan, and supporting diagnostic records with requests
Verify prior authorization and utilization review requirements with customer service

Background

Implant‑supported crowns and implant‑supported fixed partial dentures are prosthetic options to replace missing teeth resulting from accidental trauma with extraction, pathologic disorders requiring extraction, congenitally missing teeth, or congenital dental disorders. Clinical appropriateness requires a thorough dental examination, medical and dental history, a complete treatment plan, and diagnostic radiographic images (required within the preceding 12 months); when radiographs do not clearly demonstrate necessity, intra‑oral photographs and narrative treatment notes must accompany imaging. Tooth‑implant combination fixed partial dentures have been reported to show lower survival than solely implant‑ or tooth‑supported FPDs and may be considered plan‑specific for benefit eligibility. Repair or replacement of implant prosthetics (for example fractured porcelain or loose/broken screws) requires detailed narrative documentation and is dependent on group contract terms.

OpenPayer

Implant Fixed Prosthetics - Crowns and Fixed Bridges

Coverage Criteria

Coding and Radiographs

Provider Actions, Authorization & Documentation

Definitions & Standards

Background